Transcript 263642
PNEUMONIA IN THE ELDERLY
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A Primer to Clinical Documentation
WI ACDIS Chapter
Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR,
FCS, PCS, CCDS, C-CDIS
PNEUMONIA
PneumoniaInfection of the aleveoli, distal airways, and
interstitium of the lungs
Inflammatory disease of the lung characterized by
the production of a vascular response (hyperemia
and vascular permeability) and an exudate
Caused by bacteria, viruses, fungi, and parasites
Typically classified as “community acquired” or
“healthcare/hospital acquired”
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PNEUMONIA
Community Acquired Pneumonia- diagnosed
outside the hospital or is diagnosed within 48
hours after admission to the hospital in a patient
who has not been hospitalized in an acute care
setting for 2 or more days within 90 days of the
infection or has not been hospitalized or residing
in a long term care facility for more than 14 days
before the onset of symptoms.
Hospital Acquired Pneumonia/Nosocomial
Pneumonia- acquired in hospital setting.
Develops at least 48 hrs after hospital admission
Nursing Home Acquired Pneumonia- acquired in
extended care setting.
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HOSPITAL ACQUIRED PNEUMONIA
HAP
Carries highest morbidity and mortality rates of all
nosocomial infections
Adds 7-9 days to hospital stays
Increases costs by $2 billion annually
Crude mortality rates range from 30 to 70%
HAP defined as new or progressive infiltrate on
CXR plus at least two of the following:
Fever of > 37.8• C
Leukocytosis with >10,000 WBCs/uL
Production of purulent sputum
Dyspnea, hypoxemia, and pleuritic chest pain may
occur
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IMMUNOCOMPETENT VS.
IMMUNOCOMPROMISED
Immunocompromised Patients
HIV disease
Absolute neutrophil count < 1000/mcL
Current or recent exposure to myelosuppressive or
immonosuppressive drugs
Currently taking prednisone in dosage >5mg/d
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CLINICAL PRESENTATION
Temperature > 38 •C(100.4F)
Cough with/without sputum, hemoptysis
Pleuritic chest pain
Myalgia
Gastrointestinal symptoms
Dyspnea
Malaise, fatigue
Rales, rhonchi, wheezing
Egophony, bronchial breath sounds
Dullness to percussion
Atypical symptoms in older patients
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RISK FACTORS PNEUMONIA
Increased Morbidity &
Mortality
Advanced age
Alcoholism
Comorbid medical
conditions
Altered mental status
Respiratory rate >=30
breaths/minute
Hypotension (systolic
blood pressure < 90 mm
Hg or diastolic < 60 mm
Hg
Increased BUN
Overall Risk Factors
Age > 65 years
HIV or
Immunocompromised
Recent antibiotic therapy or
resistance to antibiotics
Comorbidities
Asthma
Cerebrovascular disease
COPD
CRF
CHF
Diabetes
Liver disease
Neoplastic disease
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DIAGNOSIS OF PNEUMONIA
Radiographic studies-CXR usually adequate, can have a
auscultation-radiographic disassociation, may be negative in
early phase of pneumonia
Lobar consolidation in typical pneumonia
Bilateral, more diffuse infiltrates commonly seen in atypical
pneumonia
“Chest X-Ray Negative” pneumonia (dehydration, CHF, pulmonary
fibrosis)
Blood cultures should precede antibiotic therapy
Positive in 6-20% of cases
Most commonly yielding S. pneumoniae (approx 60%), S. aureus or E.
Coli
Sputum stain and culture
> 25 WBC and < 10 squamous adequate specimen
Sputum cultures only adequate in only 50% patients, only 44% of
those samples contain pathogens
Single, predominant organism on Gram’s stain suggest etiology
Other stains indicated as appropriate (e.g., acid-fast stains for M
tuberculosis, special stains for fungi or monoclonal antibodies stains
for Pneumocystis
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ROUTES OF INFECTION
Routes of infection
Aspiration of contaminated secretions-most common
Inhalation of infected airborne droplets
Bacteremia, and
Direct extension of an acute inflammatory process
from an adjacent organ or structure
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DEFENSE MECHANISMS
In the normal respiratory system there are a
number of important defense mechanisms that
protect the lung from infection. These include:
Reflex closure of the vocal cords
Cough reflex
Mucociliary clearance
Macrophage activity
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DEFENSE MECHANISMS
Increased risk of bacterial infections associated
with impairment of defense mechanisms, as in
any of these clinical situations:
Loss of consciousness
Immunodeficiency state
Pulmonary edema
Neutropenia
Chronic airway obstruction
Viral infection
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CLASSIFICATION OF PNEUMONIA
Classification of pneumonia
Causative organism
Pattern of anatomic involvement: lobar pneumonia or
bronchopneumonia
Lobar pneumonia- exudative inflammation involving whole
lobe, or large portion of lung
90-95% cases caused by Streptococcus pneumoniae.
Sometimes caused by Kleb pneumoniae, Staphylococcus,
Streptococcus, H influenzae, or Gram negative bacteria
Bronchopneumonia
Characterized by focal areas of suppurative inflammation,
in a patchy distribution, involving one or more lobes
Streptococcus pneumoniae is most common cause of
community-acquired bronchopneumonia
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COMPLICATIONS OF PNEUMONIA
Abscess formation
Spread of the infection to the pleural cavity
(empyema)
Organization of the exudate (replacement of
exudate by fibroblasts)
Bacteremia with spread of the infection to the
distant sites
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CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum
Streptococcus
pneumoniae. Grampositive diplocci
H influenzae.
Pleomorphic gram
negative cocbacilli
Clinical Setting
Chronic
cardiopulmonary
disease; follows upper
respiratory tract
infection
Chronic
cardiopulmonary
disease; follows upper
respiratory tract
infection
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CHARACTERISTICS OF SELECTED
PNEUMONIAS
Clinical Setting
Organism; Appearance
on sputum
Staphylococcus
aurerus. Plump grampositive cocci in
clumps
Klebsiella pneumoniae
Plump gram-negative
encapsulated rods
Residence in chronic
care facility, hospital
acquired, influenza
epidemics, cystic
fibrosis,
bronchiectasis,
injection drug use
Alcohol abuse,
diabetes mellitus,
hospital acquired
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CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum
Escherichia Coli
Gram-negative rods
Pseudomonas
aeruginosa. Gram
negative rods
Clinical Setting
Hospital acquired;
rarely community
acquired
Hospital acquired,
cystic fibrosis; cystic
fibrosis,
bronchiectasis
Anaerobes Mixed flora
Aspiration, poor
dental hygiene
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CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum
Mycoplasma
pneumoniae. PMNs
and monocytes; no
bacteria
Legionella species
Clinical Setting
Young adults; summer
and fall
Summer and fall;
exposure to
contaminated
construction site, water
source, air conditioner;
community-acquired or
hospital- acquired
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CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum
Chlamydophilia
pneumoniae Nonspecific
Clinical Setting
Clinically similar to M
pneumoniae, but
prodromal symptoms
last longer (up to two
weeks). Sore throat
with hoarseness
common. Mild
pneumonia in
teenagers and young
adults
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CHARACTERISTICS OF SELECTED
PNEUMONIAS
Organism; Appearance
on sputum
Moraxella catarrhalis.
Gram-negative
diplcocci
Pneumocystis jiroveci.
Non-specific
Clinical Setting
Preexisting lung
disease; elderly;
corticosteroid or
immunosuppressive
therapy
AIDS,
immunosuppressive or
cytotoxic drug
therapy, cancer
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CDI TASK
Know Thy Antibiotic Coverage and
pharmacokinetics
Pay Attention to Minimum Inhibition
Coverage values and antibiotic selection
Query for Clinical Clarification and
Specificity when clinically appropriate
Clinical Relevance/Context is key
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INPATIENT ADMISSION PNEUMONIA
Hospitalization for pneumonia
Nursing home residents and older adults
Adults with any of the following:
Respiratory rate > 28/min
SBP <90 mmHg or 30 mm Hg below baseline
Altered mental status
Hypoxemia
Unstable comorbid illness
Multilobar pneumonia
Pleural effusion that is > 1 cm on lateral decubitus CXR &
ahs characteristics of a complicated parapneumonic effusion
on pleural fluid analysis
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PNEUMONIA SEVERITY INDEX
Pneumonia Severity Index- Risk model to assist
physicians in identifying patients higher risk of
complications and more likely to benefit from
hospitalization
Clinical guideline for physician management,
supplemented by physician clinical judgment
CDIS- cognizance of severity index when
contemplating pneumonia principal diagnosis
selection with concomitant conditions.
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PNEUMONIA SEVERITY INDEX
Patient Characteristics Points
Demographics
Male
Age (years)
Female
Age (years) – 10
Nursing home resident
+ 10
Comorbid illness
Neoplastic disease
Liver disease
Congestive heart failure
Cerebrovascular disease
Renal disease
+ 30
+ 20
+ 10
+ 10
+10
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PNEUMONIA SEVERITY INDEX
Physical examination findings
Altered mental status
+ 20
Respiratory rate >30 breaths per minute
+ 20
Systolic blood pressure < 90 mm Hg
+ 20
Temperature < 35°C (95°F) or >40°C (104°F) + 15
Pulse rate >125 beats per minute
+ 10
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PNEUMONIA SEVERITY INDEX
Laboratory and radiographic findings
Arterial pH < 7.35
+ 30
Blood urea nitrogen >64 mg per dL
(22.85 mmol per L)
+20
Sodium < 130 mEq per L (130 mmol per L) + 20
Glucose >250 mg per dL (13.87 mmol per L)
+ 10
Hematocrit < 30 percent
+ 10
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PNEUMONIA SEVERITY INDEX
Recommended Site of
Care
Risk Class
Point Total Risk Risk
lass
No
Low I
Predictors
<=70
Low
II
71 to 90
91 to 130
Low
III
Mortality
care
Recommend Site of
.1
Outpatient
.6
Outpatient
2.8
(briefly)
Inpatient
8.2
Inpatient
29.2
Inpatient
Moderate IV
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POSTOPERATIVE RESPIRATORY
FAILURE
National Quality Measures Clearinghouse Definition
Acute Respiratory Failure
Acute Respiratory Failure in the secondary
diagnosis field
518.81- Acute respiratory failure
518.84- Acute-on-Chronic respiratory failure
Discharges meeting the following criteria with
518.81 or 518.84 in secondary diagnosis field
Mechanical Ventilation for 96 consecutive hours or more - zero
or more days after the major operating room procedure code
Mechanical Ventilation for less than 96 consecutive hours or
undetermined - two or more days after the major operating
room procedure code
Reintubation - one or more days after the major operating room
procedure code
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POSTOP RESPIRATORY FAILURE CODES
518.5 Pulmonary insufficiency following trauma and
surgery
New code 518.51 Acute respiratory failure following
trauma and surgery
Respiratory failure, not otherwise specified, following
trauma and surgery
Excludes: Acute respiratory failure in other conditions
(518.81)
New code 518.52 Other pulmonary insufficiency, not
elsewhere classified, following trauma and surgery
Adult respiratory distress syndrome
Pulmonary insufficiency following:
surgery
trauma
Shock lung related to trauma and surgery
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POSTOP RESPIRATORY FAILURE CODES
New code 518.53 Acute and chronic respiratory
failure following trauma and surgery
Excludes:
Acute and chronic respiratory failure in other conditions
(518.84)
518.8 Other diseases of lung
See revisions for ICD-9 codes 518.81 and 518.82
and 518.84
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